Does Early Initiation of Dialysis Help?

Well, not according to the recent randomized, controlled trial of early versus late initiation of dialysis published online today by the New England Journal of Medicine. 


This was a multicenter randomized trial conducted in Australia and New Zealand. The hazard ratio for death among patients who had an early start of dialysis, when the estimated glomerular filtration rate was 10 to 14 mL/min, was 1.04 (95% CI 0.83 to 1.30, P=0.75), in comparison with patients who had a later start, when the estimated GFR was 5 to 7 mL/min. The investigators reported at the European Renal Association-European Dialysis and Transplant Association Congress in Munich.

A sensitivity analysis determined that there also was no significant difference in survival among patients who underwent transplantation, with a hazard ratio for early start of 1.01 (95% CI 0.81 to 1.26, P=0.92).

Nor were there differences in secondary outcomes:

• Cardiovascular events, HR for early start 1.23 (95% CI 0.97 to 1.56, P=0.09) 
• Infectious events, HR for early start 0.87 (95% CI 0.70 to 1.08, P=0.20) 
• Complications of dialysis, HR for early start 1.08 (95% CI 0.85 to 1.35,P=0.54) 

There also were no differences in quality of life, according to the investigators.. they concluded: "our study shows that among patients with progressive chronic kidney disease, clinical outcomes, including survival, are similar between patients in whom dialysis is initiated early and those for whom dialysis is electively delayed. The results show that with careful clinical management, dialysis may be delayed until either the GFR drops below 7.0 ml per minute or more traditional clinical indicators for the initiation of dialysis are present."

Now, how late is too late? Do you have a specific cut-off GFR? I try to treat the individual and start different people at different levels of GFR depending on several factors. The fact that there does not to be any significant harm in waiting, or no loss in benefit by starting earlier is comforting. I still submit the initiation of renal replacement therapy needs to be individualized, not simply generalized. Nevertheless, I welcome this study into the nephrology literature.